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Hepatitis B Vaccine - Continued who had received vaccine manufactured from plasma pools that contained plasma of homosexual men. Previous workers have reported that sera of HB vaccine recipients did not show helper-T/supressor-T ratio inversion, a finding common in AIDS patients (5).
Epidemiologic approaches to detect an association between HB vaccine and AIDS have included analysis of data on AIDS cases reported to CDC concerning their receipt of HB vaccine and monitoring rates of AIDS in groups of homosexually active men who did or did not receive HB vaccine in the vaccine trials conducted by CDC in Denver, Colorado, and San Francisco, California. To date, 68 AIDS cases have been reported among approximately 700,000 U.S. HB vaccine recipients; 65 have occurred among persons with known AIDS risk factors, while risk factors for the remaining three are under investigation. In addition, the rate of AIDS for HB vaccine recipients in CDC vaccine trials among homosexually active men in Denver and San Francisco does not differ from that for men screened for possible participation in the trials but who received no HB vaccine because they were found immune to HB.
Reported by B Poiesz, MD, R Tomar, MD, B Lehr, J Moore, PhD, State University of New York Upstate Medical Center, Syracuse Veterans Administration Medical Center, Syracuse, New York; Merck, Sharp & Dohme Research Laboratories, West Point, Pennsylvania; AIDS Br, Hepatitis Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.
Editorial Note: The Immunization Practices Advisory Committee (ACIP) (6) has recommended preexposure HB vaccination for susceptible members of the following groups in the United States: health-care workers (medical, dental, laboratory, and support groups) judged to have significant exposure to blood or blood products; clients and selected staff of institutions for the mentally retarded; hemodialysis patients; homosexually active males; users of illicit, injectable drugs; recipients of certain blood products (patients with clotting factor disorders); and household and sexual contacts of HB virus (HBV) carriers. In addition, vaccine may be warranted for classroom contacts of deinstitutionalized mentally retarded HBV carriers; special high-risk populations (Alaskan Eskimos and immigrants and refugees from areas with highly endemic disease); inmates of long-term correctional facilities, and some U.S. citizens living or traveling abroad (7). The ACIP has also recommended screening all pregnant women belonging to high-risk groups for HB and treating their newborn infants with hepatitis B immune globu'n and HB vaccine (8).
HB vaccine acceptance in the United States has been seriously hindered by the fear of possible AIDS transmission from the vaccine. The recent identification of AIDS' etiologic agent has made possible direct laboratory measurement of virus inactivation, nucleic acid presence, and serologic evidence of infection. These studies were unable to detect the AIDS virus' viral protein or nucleic acid in the purified vaccine product and clearly indicate that if virus were present, it would be killed by the manufacturing procedures. In addition, epidemiologic monitoring of AIDS cases and high-risk groups confirms the lack of AIDS transmission by HB vaccine. This information should remove a major impediment to vaccine use.
References 1. Feorino PM, Kalyanaraman VS, Haverkos HW. et al. Lymphadenopathy associated virus infection of a
blood donor-recipient pair with acquired immunodeficiency syndrome. Science 1984;225:69-72. 2. Poiesz BJ, Ruscetti FW, Gazdar AF, Bunn PA, Minna JD, Gallo RC. Detection and isolation of type C
retrovirus particles from fresh and cultured lymphocytes of a patient with cutaneous T-cell lympho
ma. Medical Sci 1980;77:7415-9. 3. Kalyanaraman VS, Sarngadharan MG, Robert-Guroff RM, et al. A new subtype of human T-cell leuke
mia virus (HTLV-II) associated with a T-cell variant of hairy cell leukemia. Science 1982:218:571-3. 4. CDC. Update: acquired immunodeficiency syndrome (AIDS) in persons with hemophilia. MMWR
1984,33:589-91. 5. Jacobson IM, Dienstag JL, Zachoval R, Hanrahan BA, Watkins E, Rubin RH. Lack of effect of hepatitis
B vaccine on T-cell phenotypes. N Engl J Med 1984;311:1030-2. 6. ACIP. Inactivated hepatitis B virus vaccine. MMWR 1982;31:317-22, 327-8.
Hepatitis B Vaccine - Continued 7. CDC. Adult immunization: recommendations of the Immunization Practices Advisory Committee
(ACIP). MMWR 1984:33:15-68S. 8. ACIP. Post-exposure prophylaxis of hepatitis B. MMWR 1984:33:285-90.
Acute Convulsions Associated with Endrin Poisoning
Between July 14, and September 26, 1984, an outbreak of acute convulsions occurred in Talagang, a wheat-growing subdistrict of the Punjab province of Pakistan. At least one case was reported in 21 (32%) of 65 villages in the subdistrict. Altogether, 192 cases, with 19 deaths, were reported. Sixty percent of the cases occurred among persons between 1 year and 9 years of age, and 80% occurred among persons under 15 years of age. Males and females were equally affected. None of the patients interviewed had a prior history of seizures.
Young children had no prodromal symptoms before the onset of seizures. They were observed to be engaged in routine activities when they collapsed suddenly, with bilateral jerking of the upper extremities followed by generalized tonic, clonic contractions and frothing or vomiting. Older patients reported having headaches and/or nausea and minor muscular spasms approximately half an hour before collapsing. Among untreated patients, seizures continued intermittently for 15 minutes to more than 2 hours. Repeated attacks were associated with hypoxia, pulmonary congestion, and death. Axillary temperatures of 37.8 C (100 F) were recorded in some patients immediately after the seizures ceased. More severely ill patients did not vomit as frequently as mildly affected patients, and they had higher temperatures. The combination of diazepam, phenobarbital, and atropine (to control secretions) was an effective therapeutic regimen in controlling symptoms. More severely affected patients were also given general anesthesia. For most patients, seizures were controlled within 1-2 hours, and patients remained sleepy for 24-48 hours, then recovered completely. Afterwards, patients did not remember the seizures.
Sera from 12 of 21 patients with convulsions had measurable levels of endrin. Values for all 21 ranged from O parts per billion (ppb) to 254 ppb (mean 17.10 ppb; median 1 ppb). Stomach contents from one of the 12 patients whose sera were positive had 307 ppb endrin. Autopsy tissues from another person contained endrin levels consistent with fatal acute exposures. Food samples collected from case homes were negative for endrin. Although 2,4dichlorophenoxyacetic acid (DDT) and benzene hexachloride (BHC) were found in the homes of many Talagang residents, there was no evidence that endrin was being used by local farmers, nor was it available in the local market.
A case-control study (25 cases, 21 and 23 from two sets of controls) did not implicate causative food or environmental factors. Nevertheless, available data suggested that a common food product (sugar) could have been contaminated during transport to a wholesale depot in the subdistrict capital – the only commercial food distribution point in Talagang then distributed to the villages. Cases clustered in villages located near the main road to the subdistrict capital. There was little to no communication between villages, but shopkeepers and village residents frequently traveled to the subdistrict capital to purchase supplies. Cotton and sugar-cane growers in the southern part of the Punjab use endrin. Several independent truckers reported delivering chemicals to these growers, then picking up loads of food in the same trucks for transport to Talagang. However, there were no records with which to verify these reports. Additional environmental and food samples from patients' homes and the wholesale food depots are still being analyzed, and results may clarify the source and route of exposure
Endrin Poisoning - Continued Reported by National Institutes of Health, Pakistan; World Health Organization, Geneva, Switzerland; Toxicology Br, Clinical Chemistry Div, Special Studies Br, Chronic Diseases Div, Center for Environmental Health, CDC. Editorial Note: Endrin is a chlorinated hydrocarbon pesticide, one of the group that includes DDT, BHC, chlordane, heptachlor, dieldrin, and aldrin. Endrin, chlordane, heptachlor, dieldrin, and aldrin are structurally similar. All have a cyclodien ring, but endrin is the most toxic. The minimum dose needed to produce a single convulsion in humans and the dose necessary for repeated nonfatal convulsions have been estimated to be 0.2-0.25 mg/kg and 1 mg/kg, respectively (1). Endrin is no longer commercially available in the United States. In Pakistan, it is imported for use in the early growth stages of cotton and sugar cane.
Animal studies have found that endrin is rapidly absorbed, metabolized, and excreted in feces, with a half-life in rats ranging from 2 to 6 days. In contrast, dieldrin is redistributed in body organs, particularly fat (2). Endrin is not persistent in animals or humans. Unlike DDT, BHC, dieldrin, and some of the other chlorinated hydrocarbons, endrin has not been found in fat samples taken from general surveys of humans exposed to chlorinated hydrocarbons, including endrin (4), nor has it been found in the blood of endrin workers, except in association with recent gross accidental exposure (1,3). Previously reported blood levels of patients poisoned by ingestion of endrin have ranged from 4 ppb to 53 ppb within the first day of
(Continued on page 693)
TABLE I. Summary-cases of specified notifiable diseases, United States
Paralytic (Calif 1)
30 4 4 85
3 64 61 35
4 2 30
'The 1983 reports which appear in this table were collected before AIDS became a notifiable condition ** There were no cases of internationally imported measles reported for this week,
TABLE III. Cases of specified notifiable diseases, United States, weeks ending
December 8, 1984 and December 10, 1983 (49th Week)